The patient came to the clinic 15-May-2017 complaining of left sciatica for 3 months. The patient was operated for "anal fissure" 6 months ago without improvement. MRI bad quality done 06-December-2016 showing chordoma at the lower half of the sacrum. Biopsy was done, confirmed chordoma nature of the lesion. The patient has difficult micturition the last 2 months.

On examination, the patient is limping with exaggerated scoliotic stance. SLRS was 40 degrees with pain in left side. There is weak dorsi and planterflexion left foot -4/5, and weak adduction of the knee 4/5. There is analgesia in the left perianal region with weak sphincter ani left side.

The patient was sent for investigations and neuro MRI of the pelvis with TWIST and spectroscopy of the lesion was performed showing complete destruction of the coccygeum and left side of the sacral bone up to the emergence of the left S2 root. The SIJs are anatomically preserved. The rectum is pushed anterior without involvement. No arterial feeders were noted. The left S2,3,4 are involved in the mass. The mass is growing behind the sacrococcygeal structures under the skin and fulfilling the pelvic cavity. Spectroscopy of the mass showed moderate elevation of Choline, NAA, lipid 1.3 and 0.9 ppm.

Skeletonization of the sacrococcygeal area. The tumor is destroying the S3 down to the coccygeum more the left side. Step wise resection was performed until the rectum was seen and the left S3 and S2 were preserved and the motor response was adequate. The tumor is highly vascularised that the patient was in need for 4 units of blood and 2 units FFP. The resected tumor was sent for histologic study. Check MRI showed that there is huge fragment in the right lower pole. This part was resected with the tumorous coccygeum. Parts of the tumor were severely adherent to the rectum, that it was impossible to remove them without violating the posterior wall of the rectum. Coagulation of these fragments and another check MRI was performed and these parts were seen. Routine closure of the wound.

Smooth postoperative recovery. The power of the left normalized and he was sciatica free. He was sent to the ward.

The final histologic result was low-grade myxoid chondrosarcoma  with CD99 and Vimentin positive and negative for S100 and E-Cadherin.

The patient has several problems, which require surgical correction, stenosis at 2 levels and spondylolisthesis.

This is the 118th case using the MultiGen. This procedure regained routine acceptance.  It became a usual part of the spine and peripheral nerves surgery. Click here for reference.

It is better not to perforate the rectum by leaving 5% of the mass, since it is benign. Time will tell the speed of the recurrence.